Bronchopulmonary dysplasia requiring tracheostomy: A review of management and outcomes

Factors associated with tracheostomy decannulation in infants with bronchopulmonary dysplasia

OBJECTIVE

Premature infants represent a unique subset of patients who may require tracheostomy. Bronchopulmonary dysplasia (BPD) is among one of the most common sequelae of prematurity contributing to the need for prolonged ventilation requiring tracheostomy after other airway options have been exhausted. Our objective is to understand socioeconomic barriers to decannulation and identify factors that accelerate safe decannulation, focusing on patients with BPD.

METHODS

An existing internal database from a tertiary pediatric hospital of patients undergoing tracheostomy prior to one year old was reviewed. Data from January 1, 2005 through December 31, 2020 was used to compare patients who were successfully decannulated to those who were not. A further subset of infants with BPD were identified and analyzed. Of those decannulated, survival analysis was used to identify factors associated with decreased time to decannulation.

RESULTS

We identified 303 infants who underwent tracheostomy at less than one year old with 125 of those infants having a diagnosis of BPD. Of the 125 infants with BPD, 44 (35.2 %) were decannulated and 81 (64.8 %) were not. There was no significant difference in sex, race, ethnicity, insurance status, comorbidities, or presence of syndromes between those patients with BPD who were decannulated and those who were not. Those who were not decannulated had a significantly longer length of hospital stay, prolonged ventilator requirements after tracheostomy, and were more likely to be discharged home on the ventilator (p = 0.030; 0.020; 0.002, respectively). Of the 44 decannulated patients, mean and median time to decannulation were 37.9 and 27.8 months respectively (range 10.8-160.6 months). There was an inverse association with decannulation and both Black race (HR: 0.30) and neurological comorbidity (HR: 0.37) on multivariate analysis. Black race, presence of syndrome, and length of ventilator dependence were significantly associated with increased time to decannulation. Time to decannulation from time off the ventilator was not significantly influenced by sex, race, ethnicity, state of residence, or insurance status, but was significantly influenced by age (95 % CI: -6.9, -0.1; P = 0.044). While time from discharge to first follow up visit did not significantly impact time to decannulation, every additional follow up visit increased time to decannulation by 3.78 months when adjusting for confounding variables.

CONCLUSION

In infants with BPD under one year requiring tracheostomy, socioeconomic factors were not found to influence likelihood of decannulation, however Black race, presence of underlying syndrome, and increased length of ventilator dependence were associated with prolonged timing. Children with more frequent follow up visits similarly had an increased time to decannulation, illustrating a vital point in the process. Ventilator weaning protocols and standardized decannulation protocols in patients with BPD, along with caregiver education, can safely expedite and facilitate decannulation.

Corticosteroid response predicts bronchopulmonary dysplasia status at 36 weeks in preterm infants treated with dexamethasone: A pilot study

IMPORTANCE

A major barrier to therapeutic development in neonates is a lack of standardized drug response measures that can be used as clinical trial endpoints. The ability to quantify treatment response in a way that aligns with relevant downstream outcomes may be useful as a surrogate marker for new therapies, such as those for bronchopulmonary dysplasia (BPD).

OBJECTIVE

To construct a measure of clinical response to dexamethasone that was well aligned with the incidence of severe BPD or death at 36 weeks' postmenstrual age.

DESIGN

Retrospective cohort study.

SETTING

Level IV Neonatal Intensive Care Unit.

PARTICIPANTS

Infants treated with dexamethasone for developing BPD between 2010 and 2020.

MAIN OUTCOME(S) AND MEASURE(S)

Two models were built based on demographics, changes in ventilatory support, and partial pressure of carbon dioxide (pCO₂ ) after dexamethasone administration. An ordinal logistic regression and regularized binary logistic model for the composite outcome were used to associate response level to BPD outcomes defined by both the 2017 BPD Collaborative and 2018 Neonatal Research Network definitions.

RESULTS

Ninety-five infants were treated with dexamethasone before 36 weeks. Compared to the baseline support and demographic data at the time of treatment, changes in ventilatory support improved ordinal model sensitivity and specificity. For the binary classification, BPD incidence was well aligned with risk levels, increasing from 16% to 59%.

CONCLUSIONS AND RELEVANCE

Incorporation of response variables as measured by changes in ventilatory parameters and pCO₂ following dexamethasone administration were associated with downstream outcomes. Incorporating drug response phenotype into a BPD model may enable more rapid development of future therapeutics.

Qualitative indications for tracheostomy and chronic mechanical ventilation in patients with severe bronchopulmonary dysplasia

BACKGROUND

The decision to pursue chronic mechanical ventilation involves a complex mix of clinical and social considerations. Understanding the medical indications to pursue tracheostomy would reduce the ambiguity for both providers and families and facilitate focus on appropriate clinical goals.

OBJECTIVE

To describe potential indications to pursue tracheostomy and chronic mechanical ventilation in infants with severe BPD (sBPD).

STUDY DESIGN

We surveyed centers participating in the Children's Hospitals Neonatal Consortium to describe their approach to proceed with tracheostomy in infants with sBPD. We requested a single representative response per institution. Question types were fixed form and free text responses.

RESULTS

The response rate was high (31/34, 91%). Tracheostomy was strongly considered when: airway malacia was present, PCO₂ ≥ 76-85 mmHg, FiO₂ ≥ 0.60, PEEP ≥ 9-11 cm H₂O, respiratory rate ≥ 61-70 breaths/min, PMA ≥ 44 weeks, and weight <10th %ile at 44 weeks PMA.

CONCLUSIONS

Understanding the range of indications utilized by high level NICUs around the country to pursue a tracheostomy in an infant with sBPD is one step toward standardizing consensus indications for tracheostomy in the future.